<!DOCTYPE html>
<html>

	<head>
		<meta charset="UTF-8">
		<title>检查申请</title>
		<link type="text/css" rel="stylesheet" href="fontsawesome/css/font-awesome.css" />
		<link type="text/css" rel="stylesheet" href="css/style.css" />
		<link type="text/css" rel="stylesheet" href="css/datepicker.css" />
		<link rel="stylesheet" type="text/css" href="css/wrap.css"/>
		<script src="js/jquery-2.2.1.min.js" type="text/javascript" charset="utf-8"></script>
		 <script src="js/wrap.js" type="text/javascript" charset="utf-8"></script>
	</head>

	<body>
		<div class="main_box">
			<h2><span></span>检查申请</h2>
			<div class="cont_box">
				<form action="#" method="post" id="user_form">
					<ul class="addpro_box adduser_box">
						<li>
							<label>就诊卡号：</label>
							<input type="text" placeholder="请输入就诊卡号" name="fullname" required data-rule-fullname="true" data-msg-required="就诊卡号不能为空" />
						</li>
						<li>
							<label>姓名：</label>
							<input type="text" placeholder="请输入姓名" name="mobile" required data-rule-mobile="true" data-msg-required="姓名不能为空" />
						</li>
						<li>
							<label>性别：</label>
							<ul class="pay_box clearfix">
								<li class="radio_box">
									<i class="fa fa-circle-thin fa-1x"></i>
									<input type="radio" name="payment" id="11" checked="checked" />
									<span id="member">男</span>
								</li>
								<li class="radio_box">
									<i class="fa fa-circle-thin fa-1x"></i>
									<input type="radio" name="payment" id="22" />
									<span>女</span>
								</li>
							</ul>
						</li>
						<li>
							<label>身份证号：</label>
							<input type="text" placeholder="请输入身份证号" name="mileage" required data-rule-mileage="true" data-msg-required="身份证号不能为空" />
						</li>
						<li>
							<label>手机号：</label>
							<input type="text" placeholder="请输入手机号" name="mileage" required data-rule-mileage="true" data-msg-required="手机号不能为空" />
						</li>
					</ul>
					<div class="cont_box">
						<input type="button" id="btnAdd" value="添加项目" class="btn btn_success" />
						<table border="0" cellspacing="0" cellpadding="0" class="table">
							<thead>
								<tr>
									<th>订单号</th>
									<th>金额</th>
									<th>支付方式</th>
									<th>会员</th>
									<th>手机号</th>
									<th>状态</th>
									<th>开单日期</th>
									<th>订单备注</th>
									<th width="200">操作</th>
								</tr>
							</thead>
							<tbody>
								<tr id="1">
									<!--此处id为进行编辑或删除时该条数据的唯一标识-->
									<td>10000563</td>
									<td>100.00</td>
									<td>会员</td>
									<td>张三</td>
									<td>18696532635</td>
									<td>已支付</td>
									<td>2017-03-21</td>
									<td width="200">
										<div class="order_remark">备注一下</div>
									</td>
									<td>
										<a href="javascript:void(0);" class="table_btn table_info detail_btn">
											<i class="fa fa-eye"></i>
											<span>删除</span>
										</a>
									</td>
								</tr>
								<tr id="2">
									<!--此处id为进行编辑或删除时该条数据的唯一标识-->
									<td>10000563</td>
									<td>100.00</td>
									<td>会员</td>
									<td>李四</td>
									<td>18696532635</td>
									<td>已退单</td>
									<td>2017-03-21</td>
									<td>备注一下</td>
									<td>
										<a href="javascript:void(0);" class="table_btn table_info detail_btn">
											<i class="fa fa-eye"></i>
											<span>删除</span>
										</a>
									</td>
								</tr>
							</tbody>
						</table>
					</div>
					<div class="probtn_box clearfix">
						<input type="submit" value="发放就诊卡" class="btn blue_btn" />
					</div>
				</form>
			</div>
		</div>
		<div class="bgc">
		</div>

		<div class="newData">
			<div class="title">
				<span id="span1">添加标题</span>
				<span id="span2">x</span>
			</div>

			<div class="center">
				课程名称:&nbsp;<input type="text" name="" id="input1" value="" placeholder="请输入课程名称" />
				<br /><br /><br /> 所属院校:&nbsp;
				<input type="text" name="" id="input2" value="未来学院" />
			</div>

			<div class="bottom">
				<button id="button2">提交</button>
			</div>
		</div>
	</body>

</html>